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Chick-fil-A 2017-2018 Mom Panel Registration
If you are interested in applying to be a member of the Chick-fil-A Mom Panel, please fill in the fields and answer the questions below.
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1.
Contact Information
(Required.)
First and Last Name:
*
Address:
*
Address 2:
City/Town:
*
State:
*
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP:
*
Email Address:
*
Phone Number:
2.
Please select your age group from the categories below.
18-29
30-36
37-41
42-50
51-59
60+
3.
Please indicate the number of children in your household.
0
1
2
3
4
5
6+
4.
Please select the age of your children. Select all that apply.
Under 2
2-3
4-5
6-7
8-9
10-11
12-13
14-15
16+
5.
What is your ethnicity?
Caucasian
African American
Hispanic
Asian
Native American
Indian
Pacific Islander
Prefer not to answer
Other (please specify)
6.
How would you classify your current career status?
Full-time in-home working mother
Full-time outside the home working mother
Part-time in-home working mother
Part-time outside the home working mother
In-home mother not contributing income to the family
7.
What kind of school(s) do your child(ren) attend? Please select all that apply.
Public School
Private School
Homeschool
Other (please specify)
8.
Were you a part of the 2016-17 Chick-fil-A Mom Panel?
Yes
No
9.
Please share links for your social media channels/accounts below to those that apply.
Blog URL
Twitter
Facebook
Pinterest
Instagram
Google Plus
YouTube Channel
Tumblr
Periscope
Other
10.
Please share metrics for your social media channels/accounts below to those that apply.
Average Monthly Blog Readers
Twitter Followers
Facebook Friends/Fans
Pinterest Followers
Instagram Followers
Google Plus Followers
YouTube Channel Subscribers
Tumblr Followers
Periscope Followers
Other metrics you’d like to share
11.
Approximately how many moms do you communicate with OFFLINE on a weekly basis? (through school, PTA/PTO, moms groups, athletic leagues, workplace, etc.)
Under 20 Moms
20-50 Moms
50-100 Moms
Over 100 Moms
Over 1,000 Moms
12.
Please tell us about any other ways you connect with Moms. (Example: Playgroup and meet 30-40 moms each week or month; Write for a parenting publication that reaches 30K families each month, etc.)
13.
Please indicate which of the following positions/titles you hold and/or participate in. Please select all that apply:
Author
Columnist for offline publication
Columnist/Contributor for online publication
Business Owner
PTA/PTO Leader
Church/Synagogue Group Leader
TV Contributor
School Board Member
Local Government/City Position
Teacher/Childcare Professional
Coach/Instructor
Other (please specify)
14.
Are you currently partnering with any other brands or companies?
Yes
No
If YES, please list which ones below:
15.
How often do you frequent Chick-fil-A?
More than 2-3 times per week
2-3 times per week
Once per week
2-3 times per month
Once per month
2-3 times per year
Once per year
Less than once per year
16.
On a scale of 1 to 5, with 5 being extremely positive, how would you rate your overall impression of Chick-fil-A?
1
2
3
4
5
Never been to Chick-fil-A
17.
How often do you take advantage of the following Chick-fil-A services?
Weekly
Twice a Month
Once a Month
A Few Times a Year
Never
Kid's Meals
Weekly
Twice a Month
Once a Month
A Few Times a Year
Never
Playground
Weekly
Twice a Month
Once a Month
A Few Times a Year
Never
Trays/Catering
Weekly
Twice a Month
Once a Month
A Few Times a Year
Never
Family Night Events
Weekly
Twice a Month
Once a Month
A Few Times a Year
Never
Community Events
Weekly
Twice a Month
Once a Month
A Few Times a Year
Never
Wifi
Weekly
Twice a Month
Once a Month
A Few Times a Year
Never
18.
How often do you discuss Chick-fil-A with family and friends?
Daily
Weekly
Twice a Month
Once a Month
A Few Times a Year
Never
19.
What is it that you love most about Chick-fil-A?
20.
What would you like to see more of at Chick-fil-A?
21.
Is there anything else you’d like to tell us about why you’d like to be a part of the Chick-fil-A Mom Panel?
